Provider Demographics
NPI:1841245024
Name:CHILDS, CLINTON R (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:R
Last Name:CHILDS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140728
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014
Mailing Address - Country:US
Mailing Address - Phone:918-258-9990
Mailing Address - Fax:918-994-4277
Practice Address - Street 1:1130 E LANSING
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-258-9990
Practice Address - Fax:918-994-4277
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3130207Q00000X
OK19517207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX047146801Medicaid
TX080175359OtherRR MEDICARE
TX047146802Medicaid
TX8A9711OtherBCBS
TX047146802Medicaid
TX88X274Medicare ID - Type Unspecified
TX047146801Medicaid